|
IOHEXOL 180 MG IODINE/ML IT SOLN 10 ML VIAL
|
Facility
|
OP
|
$280.35
|
|
|
Service Code
|
HCPCS Q9965
|
| Hospital Charge Code |
10319
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.91 |
| Max. Negotiated Rate |
$260.73 |
| Rate for Payer: Aetna Commercial |
$236.62
|
| Rate for Payer: Aetna Medicare |
$89.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$86.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$161.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$175.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$103.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$98.68
|
| Rate for Payer: Cash Price |
$168.21
|
| Rate for Payer: Centivo All Commercial |
$152.51
|
| Rate for Payer: Cigna All Commercial |
$241.94
|
| Rate for Payer: CORVEL All Commercial |
$260.73
|
| Rate for Payer: Coventry All Commercial |
$246.71
|
| Rate for Payer: Encore All Commercial |
$258.06
|
| Rate for Payer: Frontpath All Commercial |
$257.92
|
| Rate for Payer: Humana ChoiceCare |
$242.14
|
| Rate for Payer: Humana Medicare |
$89.71
|
| Rate for Payer: Lucent All Commercial |
$152.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$252.31
|
| Rate for Payer: PHCS All Commercial |
$210.26
|
| Rate for Payer: PHP All Commercial |
$212.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$109.34
|
| Rate for Payer: Sagamore Health Network All Products |
$216.43
|
| Rate for Payer: Signature Care EPO |
$232.69
|
| Rate for Payer: Signature Care PPO |
$246.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$238.30
|
| Rate for Payer: United Healthcare Commercial |
$220.92
|
| Rate for Payer: United Healthcare Medicare |
$89.71
|
|
|
IOHEXOL 180 MG IODINE/ML IT SOLN 10 ML VIAL
|
Facility
|
IP
|
$280.35
|
|
|
Service Code
|
HCPCS Q9965
|
| Hospital Charge Code |
10319
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$210.26 |
| Max. Negotiated Rate |
$260.73 |
| Rate for Payer: Aetna Commercial |
$242.22
|
| Rate for Payer: Cash Price |
$168.21
|
| Rate for Payer: Cigna All Commercial |
$241.94
|
| Rate for Payer: CORVEL All Commercial |
$260.73
|
| Rate for Payer: Coventry All Commercial |
$246.71
|
| Rate for Payer: Encore All Commercial |
$258.06
|
| Rate for Payer: Frontpath All Commercial |
$257.92
|
| Rate for Payer: Humana ChoiceCare |
$242.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$252.31
|
| Rate for Payer: PHCS All Commercial |
$210.26
|
| Rate for Payer: PHP All Commercial |
$212.62
|
| Rate for Payer: Sagamore Health Network All Products |
$216.43
|
| Rate for Payer: Signature Care EPO |
$232.69
|
| Rate for Payer: Signature Care PPO |
$246.71
|
| Rate for Payer: United Healthcare Commercial |
$220.92
|
|
|
IOHEXOL 300 MG IODINE/ML IV SOLN 10 ML VIAL
|
Facility
|
OP
|
$281.40
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.23 |
| Max. Negotiated Rate |
$261.70 |
| Rate for Payer: Aetna Commercial |
$237.50
|
| Rate for Payer: Aetna Medicare |
$90.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$87.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$161.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$175.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$103.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$99.05
|
| Rate for Payer: Cash Price |
$168.84
|
| Rate for Payer: Centivo All Commercial |
$153.08
|
| Rate for Payer: Cigna All Commercial |
$242.85
|
| Rate for Payer: CORVEL All Commercial |
$261.70
|
| Rate for Payer: Coventry All Commercial |
$247.63
|
| Rate for Payer: Encore All Commercial |
$259.03
|
| Rate for Payer: Frontpath All Commercial |
$258.89
|
| Rate for Payer: Humana ChoiceCare |
$243.05
|
| Rate for Payer: Humana Medicare |
$90.05
|
| Rate for Payer: Lucent All Commercial |
$153.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$253.26
|
| Rate for Payer: PHCS All Commercial |
$211.05
|
| Rate for Payer: PHP All Commercial |
$213.41
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$109.75
|
| Rate for Payer: Sagamore Health Network All Products |
$217.24
|
| Rate for Payer: Signature Care EPO |
$233.56
|
| Rate for Payer: Signature Care PPO |
$247.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$239.19
|
| Rate for Payer: United Healthcare Commercial |
$221.74
|
| Rate for Payer: United Healthcare Medicare |
$90.05
|
|
|
IOHEXOL 300 MG IODINE/ML IV SOLN 10 ML VIAL
|
Facility
|
IP
|
$281.40
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10322
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$211.05 |
| Max. Negotiated Rate |
$261.70 |
| Rate for Payer: Aetna Commercial |
$243.13
|
| Rate for Payer: Cash Price |
$168.84
|
| Rate for Payer: Cigna All Commercial |
$242.85
|
| Rate for Payer: CORVEL All Commercial |
$261.70
|
| Rate for Payer: Coventry All Commercial |
$247.63
|
| Rate for Payer: Encore All Commercial |
$259.03
|
| Rate for Payer: Frontpath All Commercial |
$258.89
|
| Rate for Payer: Humana ChoiceCare |
$243.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$253.26
|
| Rate for Payer: PHCS All Commercial |
$211.05
|
| Rate for Payer: PHP All Commercial |
$213.41
|
| Rate for Payer: Sagamore Health Network All Products |
$217.24
|
| Rate for Payer: Signature Care EPO |
$233.56
|
| Rate for Payer: Signature Care PPO |
$247.63
|
| Rate for Payer: United Healthcare Commercial |
$221.74
|
|
|
IOHEXOL 300 MG IODINE/ML IV SOLN 50 ML BTL
|
Facility
|
OP
|
$324.45
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.58 |
| Max. Negotiated Rate |
$301.74 |
| Rate for Payer: Aetna Commercial |
$273.84
|
| Rate for Payer: Aetna Medicare |
$103.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$100.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$186.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$202.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$119.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$114.21
|
| Rate for Payer: Cash Price |
$194.67
|
| Rate for Payer: Centivo All Commercial |
$176.50
|
| Rate for Payer: Cigna All Commercial |
$280.00
|
| Rate for Payer: CORVEL All Commercial |
$301.74
|
| Rate for Payer: Coventry All Commercial |
$285.52
|
| Rate for Payer: Encore All Commercial |
$298.66
|
| Rate for Payer: Frontpath All Commercial |
$298.49
|
| Rate for Payer: Humana ChoiceCare |
$280.23
|
| Rate for Payer: Humana Medicare |
$103.82
|
| Rate for Payer: Lucent All Commercial |
$176.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$292.00
|
| Rate for Payer: PHCS All Commercial |
$243.34
|
| Rate for Payer: PHP All Commercial |
$246.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$126.54
|
| Rate for Payer: Sagamore Health Network All Products |
$250.48
|
| Rate for Payer: Signature Care EPO |
$269.29
|
| Rate for Payer: Signature Care PPO |
$285.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$275.78
|
| Rate for Payer: United Healthcare Commercial |
$255.67
|
| Rate for Payer: United Healthcare Medicare |
$103.82
|
|
|
IOHEXOL 300 MG IODINE/ML IV SOLN 50 ML BTL
|
Facility
|
IP
|
$324.45
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103221
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$243.34 |
| Max. Negotiated Rate |
$301.74 |
| Rate for Payer: Aetna Commercial |
$280.32
|
| Rate for Payer: Cash Price |
$194.67
|
| Rate for Payer: Cigna All Commercial |
$280.00
|
| Rate for Payer: CORVEL All Commercial |
$301.74
|
| Rate for Payer: Coventry All Commercial |
$285.52
|
| Rate for Payer: Encore All Commercial |
$298.66
|
| Rate for Payer: Frontpath All Commercial |
$298.49
|
| Rate for Payer: Humana ChoiceCare |
$280.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$292.00
|
| Rate for Payer: PHCS All Commercial |
$243.34
|
| Rate for Payer: PHP All Commercial |
$246.06
|
| Rate for Payer: Sagamore Health Network All Products |
$250.48
|
| Rate for Payer: Signature Care EPO |
$269.29
|
| Rate for Payer: Signature Care PPO |
$285.52
|
| Rate for Payer: United Healthcare Commercial |
$255.67
|
|
|
IOHEXOL 350 MG IODINE/ML IV SOLN 100 ML BTL
|
Facility
|
OP
|
$504.50
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103231
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$156.40 |
| Max. Negotiated Rate |
$469.19 |
| Rate for Payer: Aetna Commercial |
$425.80
|
| Rate for Payer: Aetna Medicare |
$161.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$156.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$289.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$315.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$185.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$177.58
|
| Rate for Payer: Cash Price |
$302.70
|
| Rate for Payer: Centivo All Commercial |
$274.45
|
| Rate for Payer: Cigna All Commercial |
$435.38
|
| Rate for Payer: CORVEL All Commercial |
$469.19
|
| Rate for Payer: Coventry All Commercial |
$443.96
|
| Rate for Payer: Encore All Commercial |
$464.39
|
| Rate for Payer: Frontpath All Commercial |
$464.14
|
| Rate for Payer: Humana ChoiceCare |
$435.74
|
| Rate for Payer: Humana Medicare |
$161.44
|
| Rate for Payer: Lucent All Commercial |
$274.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$454.05
|
| Rate for Payer: PHCS All Commercial |
$378.38
|
| Rate for Payer: PHP All Commercial |
$382.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$196.75
|
| Rate for Payer: Sagamore Health Network All Products |
$389.47
|
| Rate for Payer: Signature Care EPO |
$418.74
|
| Rate for Payer: Signature Care PPO |
$443.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$428.82
|
| Rate for Payer: United Healthcare Commercial |
$397.55
|
| Rate for Payer: United Healthcare Medicare |
$161.44
|
|
|
IOHEXOL 350 MG IODINE/ML IV SOLN 100 ML BTL
|
Facility
|
IP
|
$504.50
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103231
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$378.38 |
| Max. Negotiated Rate |
$469.19 |
| Rate for Payer: Aetna Commercial |
$435.89
|
| Rate for Payer: Cash Price |
$302.70
|
| Rate for Payer: Cigna All Commercial |
$435.38
|
| Rate for Payer: CORVEL All Commercial |
$469.19
|
| Rate for Payer: Coventry All Commercial |
$443.96
|
| Rate for Payer: Encore All Commercial |
$464.39
|
| Rate for Payer: Frontpath All Commercial |
$464.14
|
| Rate for Payer: Humana ChoiceCare |
$435.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$454.05
|
| Rate for Payer: PHCS All Commercial |
$378.38
|
| Rate for Payer: PHP All Commercial |
$382.61
|
| Rate for Payer: Sagamore Health Network All Products |
$389.47
|
| Rate for Payer: Signature Care EPO |
$418.74
|
| Rate for Payer: Signature Care PPO |
$443.96
|
| Rate for Payer: United Healthcare Commercial |
$397.55
|
|
|
IOHEXOL 350 MG IODINE/ML IV SOLN 50 ML BTL
|
Facility
|
IP
|
$303.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10323
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$227.25 |
| Max. Negotiated Rate |
$281.79 |
| Rate for Payer: Aetna Commercial |
$261.79
|
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Cigna All Commercial |
$261.49
|
| Rate for Payer: CORVEL All Commercial |
$281.79
|
| Rate for Payer: Coventry All Commercial |
$266.64
|
| Rate for Payer: Encore All Commercial |
$278.91
|
| Rate for Payer: Frontpath All Commercial |
$278.76
|
| Rate for Payer: Humana ChoiceCare |
$261.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$272.70
|
| Rate for Payer: PHCS All Commercial |
$227.25
|
| Rate for Payer: PHP All Commercial |
$229.80
|
| Rate for Payer: Sagamore Health Network All Products |
$233.92
|
| Rate for Payer: Signature Care EPO |
$251.49
|
| Rate for Payer: Signature Care PPO |
$266.64
|
| Rate for Payer: United Healthcare Commercial |
$238.76
|
|
|
IOHEXOL 350 MG IODINE/ML IV SOLN 50 ML BTL
|
Facility
|
OP
|
$303.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.93 |
| Max. Negotiated Rate |
$281.79 |
| Rate for Payer: Aetna Commercial |
$255.73
|
| Rate for Payer: Aetna Medicare |
$96.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$93.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$174.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$189.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$111.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$106.66
|
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Centivo All Commercial |
$164.83
|
| Rate for Payer: Cigna All Commercial |
$261.49
|
| Rate for Payer: CORVEL All Commercial |
$281.79
|
| Rate for Payer: Coventry All Commercial |
$266.64
|
| Rate for Payer: Encore All Commercial |
$278.91
|
| Rate for Payer: Frontpath All Commercial |
$278.76
|
| Rate for Payer: Humana ChoiceCare |
$261.70
|
| Rate for Payer: Humana Medicare |
$96.96
|
| Rate for Payer: Lucent All Commercial |
$164.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$272.70
|
| Rate for Payer: PHCS All Commercial |
$227.25
|
| Rate for Payer: PHP All Commercial |
$229.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$118.17
|
| Rate for Payer: Sagamore Health Network All Products |
$233.92
|
| Rate for Payer: Signature Care EPO |
$251.49
|
| Rate for Payer: Signature Care PPO |
$266.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$257.55
|
| Rate for Payer: United Healthcare Commercial |
$238.76
|
| Rate for Payer: United Healthcare Medicare |
$96.96
|
|
|
IOHEXOL 350 MG IODINE/ML IV SOLN 75 ML BTL
|
Facility
|
OP
|
$453.15
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
40810323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.48 |
| Max. Negotiated Rate |
$421.43 |
| Rate for Payer: Aetna Commercial |
$382.46
|
| Rate for Payer: Aetna Medicare |
$145.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$140.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$260.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$283.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$166.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$159.51
|
| Rate for Payer: Cash Price |
$271.89
|
| Rate for Payer: Centivo All Commercial |
$246.51
|
| Rate for Payer: Cigna All Commercial |
$391.07
|
| Rate for Payer: CORVEL All Commercial |
$421.43
|
| Rate for Payer: Coventry All Commercial |
$398.77
|
| Rate for Payer: Encore All Commercial |
$417.12
|
| Rate for Payer: Frontpath All Commercial |
$416.90
|
| Rate for Payer: Humana ChoiceCare |
$391.39
|
| Rate for Payer: Humana Medicare |
$145.01
|
| Rate for Payer: Lucent All Commercial |
$246.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$407.83
|
| Rate for Payer: PHCS All Commercial |
$339.86
|
| Rate for Payer: PHP All Commercial |
$343.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$176.73
|
| Rate for Payer: Sagamore Health Network All Products |
$349.83
|
| Rate for Payer: Signature Care EPO |
$376.11
|
| Rate for Payer: Signature Care PPO |
$398.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$385.18
|
| Rate for Payer: United Healthcare Commercial |
$357.08
|
| Rate for Payer: United Healthcare Medicare |
$145.01
|
|
|
IOHEXOL 350 MG IODINE/ML IV SOLN 75 ML BTL
|
Facility
|
IP
|
$453.15
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
40810323
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$339.86 |
| Max. Negotiated Rate |
$421.43 |
| Rate for Payer: Aetna Commercial |
$391.52
|
| Rate for Payer: Cash Price |
$271.89
|
| Rate for Payer: Cigna All Commercial |
$391.07
|
| Rate for Payer: CORVEL All Commercial |
$421.43
|
| Rate for Payer: Coventry All Commercial |
$398.77
|
| Rate for Payer: Encore All Commercial |
$417.12
|
| Rate for Payer: Frontpath All Commercial |
$416.90
|
| Rate for Payer: Humana ChoiceCare |
$391.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$407.83
|
| Rate for Payer: PHCS All Commercial |
$339.86
|
| Rate for Payer: PHP All Commercial |
$343.67
|
| Rate for Payer: Sagamore Health Network All Products |
$349.83
|
| Rate for Payer: Signature Care EPO |
$376.11
|
| Rate for Payer: Signature Care PPO |
$398.77
|
| Rate for Payer: United Healthcare Commercial |
$357.08
|
|
|
IOPAMIDOL 41 % IT SOLN 10 ML VIAL
|
Facility
|
OP
|
$367.80
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
40810325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.02 |
| Max. Negotiated Rate |
$342.05 |
| Rate for Payer: Aetna Commercial |
$310.42
|
| Rate for Payer: Aetna Medicare |
$117.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$114.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$211.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$229.91
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$135.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$129.47
|
| Rate for Payer: Cash Price |
$220.68
|
| Rate for Payer: Centivo All Commercial |
$200.08
|
| Rate for Payer: Cigna All Commercial |
$317.41
|
| Rate for Payer: CORVEL All Commercial |
$342.05
|
| Rate for Payer: Coventry All Commercial |
$323.66
|
| Rate for Payer: Encore All Commercial |
$338.56
|
| Rate for Payer: Frontpath All Commercial |
$338.38
|
| Rate for Payer: Humana ChoiceCare |
$317.67
|
| Rate for Payer: Humana Medicare |
$117.70
|
| Rate for Payer: Lucent All Commercial |
$200.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$331.02
|
| Rate for Payer: PHCS All Commercial |
$275.85
|
| Rate for Payer: PHP All Commercial |
$278.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$143.44
|
| Rate for Payer: Sagamore Health Network All Products |
$283.94
|
| Rate for Payer: Signature Care EPO |
$305.27
|
| Rate for Payer: Signature Care PPO |
$323.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$312.63
|
| Rate for Payer: United Healthcare Commercial |
$289.83
|
| Rate for Payer: United Healthcare Medicare |
$117.70
|
|
|
IOPAMIDOL 41 % IT SOLN 10 ML VIAL
|
Facility
|
IP
|
$367.80
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
40810325
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$275.85 |
| Max. Negotiated Rate |
$342.05 |
| Rate for Payer: Aetna Commercial |
$317.78
|
| Rate for Payer: Cash Price |
$220.68
|
| Rate for Payer: Cigna All Commercial |
$317.41
|
| Rate for Payer: CORVEL All Commercial |
$342.05
|
| Rate for Payer: Coventry All Commercial |
$323.66
|
| Rate for Payer: Encore All Commercial |
$338.56
|
| Rate for Payer: Frontpath All Commercial |
$338.38
|
| Rate for Payer: Humana ChoiceCare |
$317.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$331.02
|
| Rate for Payer: PHCS All Commercial |
$275.85
|
| Rate for Payer: PHP All Commercial |
$278.94
|
| Rate for Payer: Sagamore Health Network All Products |
$283.94
|
| Rate for Payer: Signature Care EPO |
$305.27
|
| Rate for Payer: Signature Care PPO |
$323.66
|
| Rate for Payer: United Healthcare Commercial |
$289.83
|
|
|
IOPAMIDOL 41 % IT SOLN 20 ML VIAL
|
Facility
|
IP
|
$531.24
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
10325
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$398.43 |
| Max. Negotiated Rate |
$494.05 |
| Rate for Payer: Aetna Commercial |
$458.99
|
| Rate for Payer: Cash Price |
$318.74
|
| Rate for Payer: Cigna All Commercial |
$458.46
|
| Rate for Payer: CORVEL All Commercial |
$494.05
|
| Rate for Payer: Coventry All Commercial |
$467.49
|
| Rate for Payer: Encore All Commercial |
$489.01
|
| Rate for Payer: Frontpath All Commercial |
$488.74
|
| Rate for Payer: Humana ChoiceCare |
$458.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$478.12
|
| Rate for Payer: PHCS All Commercial |
$398.43
|
| Rate for Payer: PHP All Commercial |
$402.89
|
| Rate for Payer: Sagamore Health Network All Products |
$410.12
|
| Rate for Payer: Signature Care EPO |
$440.93
|
| Rate for Payer: Signature Care PPO |
$467.49
|
| Rate for Payer: United Healthcare Commercial |
$418.62
|
|
|
IOPAMIDOL 41 % IT SOLN 20 ML VIAL
|
Facility
|
OP
|
$531.24
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
10325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.68 |
| Max. Negotiated Rate |
$494.05 |
| Rate for Payer: Aetna Commercial |
$448.37
|
| Rate for Payer: Aetna Medicare |
$170.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$164.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$305.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$332.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$195.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$187.00
|
| Rate for Payer: Cash Price |
$318.74
|
| Rate for Payer: Centivo All Commercial |
$288.99
|
| Rate for Payer: Cigna All Commercial |
$458.46
|
| Rate for Payer: CORVEL All Commercial |
$494.05
|
| Rate for Payer: Coventry All Commercial |
$467.49
|
| Rate for Payer: Encore All Commercial |
$489.01
|
| Rate for Payer: Frontpath All Commercial |
$488.74
|
| Rate for Payer: Humana ChoiceCare |
$458.83
|
| Rate for Payer: Humana Medicare |
$170.00
|
| Rate for Payer: Lucent All Commercial |
$288.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$478.12
|
| Rate for Payer: PHCS All Commercial |
$398.43
|
| Rate for Payer: PHP All Commercial |
$402.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$207.18
|
| Rate for Payer: Sagamore Health Network All Products |
$410.12
|
| Rate for Payer: Signature Care EPO |
$440.93
|
| Rate for Payer: Signature Care PPO |
$467.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$451.55
|
| Rate for Payer: United Healthcare Commercial |
$418.62
|
| Rate for Payer: United Healthcare Medicare |
$170.00
|
|
|
IOPAMIDOL 61 % IT SOLN 15 ML VIAL
|
Facility
|
OP
|
$978.98
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$303.48 |
| Max. Negotiated Rate |
$910.45 |
| Rate for Payer: Aetna Commercial |
$826.25
|
| Rate for Payer: Aetna Medicare |
$313.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$303.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$562.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$611.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$360.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$344.60
|
| Rate for Payer: Cash Price |
$587.39
|
| Rate for Payer: Centivo All Commercial |
$532.56
|
| Rate for Payer: Cigna All Commercial |
$844.86
|
| Rate for Payer: CORVEL All Commercial |
$910.45
|
| Rate for Payer: Coventry All Commercial |
$861.50
|
| Rate for Payer: Encore All Commercial |
$901.15
|
| Rate for Payer: Frontpath All Commercial |
$900.66
|
| Rate for Payer: Humana ChoiceCare |
$845.54
|
| Rate for Payer: Humana Medicare |
$313.27
|
| Rate for Payer: Lucent All Commercial |
$532.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$881.08
|
| Rate for Payer: PHCS All Commercial |
$734.23
|
| Rate for Payer: PHP All Commercial |
$742.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$381.80
|
| Rate for Payer: Sagamore Health Network All Products |
$755.77
|
| Rate for Payer: Signature Care EPO |
$812.55
|
| Rate for Payer: Signature Care PPO |
$861.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$832.13
|
| Rate for Payer: United Healthcare Commercial |
$771.43
|
| Rate for Payer: United Healthcare Medicare |
$313.27
|
|
|
IOPAMIDOL 61 % IT SOLN 15 ML VIAL
|
Facility
|
IP
|
$978.98
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10327
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$734.23 |
| Max. Negotiated Rate |
$910.45 |
| Rate for Payer: Aetna Commercial |
$845.83
|
| Rate for Payer: Cash Price |
$587.39
|
| Rate for Payer: Cigna All Commercial |
$844.86
|
| Rate for Payer: CORVEL All Commercial |
$910.45
|
| Rate for Payer: Coventry All Commercial |
$861.50
|
| Rate for Payer: Encore All Commercial |
$901.15
|
| Rate for Payer: Frontpath All Commercial |
$900.66
|
| Rate for Payer: Humana ChoiceCare |
$845.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$881.08
|
| Rate for Payer: PHCS All Commercial |
$734.23
|
| Rate for Payer: PHP All Commercial |
$742.45
|
| Rate for Payer: Sagamore Health Network All Products |
$755.77
|
| Rate for Payer: Signature Care EPO |
$812.55
|
| Rate for Payer: Signature Care PPO |
$861.50
|
| Rate for Payer: United Healthcare Commercial |
$771.43
|
|
|
IOPAMIDOL 61 % IV SOLN 50 ML VIAL
|
Facility
|
IP
|
$164.15
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
27737
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$123.11 |
| Max. Negotiated Rate |
$152.66 |
| Rate for Payer: Aetna Commercial |
$141.83
|
| Rate for Payer: Cash Price |
$98.49
|
| Rate for Payer: Cigna All Commercial |
$141.66
|
| Rate for Payer: CORVEL All Commercial |
$152.66
|
| Rate for Payer: Coventry All Commercial |
$144.45
|
| Rate for Payer: Encore All Commercial |
$151.10
|
| Rate for Payer: Frontpath All Commercial |
$151.02
|
| Rate for Payer: Humana ChoiceCare |
$141.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$147.74
|
| Rate for Payer: PHCS All Commercial |
$123.11
|
| Rate for Payer: PHP All Commercial |
$124.49
|
| Rate for Payer: Sagamore Health Network All Products |
$126.72
|
| Rate for Payer: Signature Care EPO |
$136.24
|
| Rate for Payer: Signature Care PPO |
$144.45
|
| Rate for Payer: United Healthcare Commercial |
$129.35
|
|
|
IOPAMIDOL 61 % IV SOLN 50 ML VIAL
|
Facility
|
OP
|
$164.15
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
27737
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.89 |
| Max. Negotiated Rate |
$152.66 |
| Rate for Payer: Aetna Commercial |
$138.54
|
| Rate for Payer: Aetna Medicare |
$52.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$50.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$94.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$102.61
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$60.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$57.78
|
| Rate for Payer: Cash Price |
$98.49
|
| Rate for Payer: Centivo All Commercial |
$89.30
|
| Rate for Payer: Cigna All Commercial |
$141.66
|
| Rate for Payer: CORVEL All Commercial |
$152.66
|
| Rate for Payer: Coventry All Commercial |
$144.45
|
| Rate for Payer: Encore All Commercial |
$151.10
|
| Rate for Payer: Frontpath All Commercial |
$151.02
|
| Rate for Payer: Humana ChoiceCare |
$141.78
|
| Rate for Payer: Humana Medicare |
$52.53
|
| Rate for Payer: Lucent All Commercial |
$89.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$147.74
|
| Rate for Payer: PHCS All Commercial |
$123.11
|
| Rate for Payer: PHP All Commercial |
$124.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$64.02
|
| Rate for Payer: Sagamore Health Network All Products |
$126.72
|
| Rate for Payer: Signature Care EPO |
$136.24
|
| Rate for Payer: Signature Care PPO |
$144.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$139.53
|
| Rate for Payer: United Healthcare Commercial |
$129.35
|
| Rate for Payer: United Healthcare Medicare |
$52.53
|
|
|
IOPAMIDOL 76 % IV SOLN 100 ML BTL
|
Facility
|
IP
|
$304.80
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10328
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$228.60 |
| Max. Negotiated Rate |
$283.46 |
| Rate for Payer: Aetna Commercial |
$263.35
|
| Rate for Payer: Cash Price |
$182.88
|
| Rate for Payer: Cigna All Commercial |
$263.04
|
| Rate for Payer: CORVEL All Commercial |
$283.46
|
| Rate for Payer: Coventry All Commercial |
$268.22
|
| Rate for Payer: Encore All Commercial |
$280.57
|
| Rate for Payer: Frontpath All Commercial |
$280.42
|
| Rate for Payer: Humana ChoiceCare |
$263.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$274.32
|
| Rate for Payer: PHCS All Commercial |
$228.60
|
| Rate for Payer: PHP All Commercial |
$231.16
|
| Rate for Payer: Sagamore Health Network All Products |
$235.31
|
| Rate for Payer: Signature Care EPO |
$252.98
|
| Rate for Payer: Signature Care PPO |
$268.22
|
| Rate for Payer: United Healthcare Commercial |
$240.18
|
|
|
IOPAMIDOL 76 % IV SOLN 100 ML BTL
|
Facility
|
OP
|
$304.80
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
10328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.49 |
| Max. Negotiated Rate |
$283.46 |
| Rate for Payer: Aetna Commercial |
$257.25
|
| Rate for Payer: Aetna Medicare |
$97.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$94.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$175.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$190.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$112.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$107.29
|
| Rate for Payer: Cash Price |
$182.88
|
| Rate for Payer: Centivo All Commercial |
$165.81
|
| Rate for Payer: Cigna All Commercial |
$263.04
|
| Rate for Payer: CORVEL All Commercial |
$283.46
|
| Rate for Payer: Coventry All Commercial |
$268.22
|
| Rate for Payer: Encore All Commercial |
$280.57
|
| Rate for Payer: Frontpath All Commercial |
$280.42
|
| Rate for Payer: Humana ChoiceCare |
$263.26
|
| Rate for Payer: Humana Medicare |
$97.54
|
| Rate for Payer: Lucent All Commercial |
$165.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$274.32
|
| Rate for Payer: PHCS All Commercial |
$228.60
|
| Rate for Payer: PHP All Commercial |
$231.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$118.87
|
| Rate for Payer: Sagamore Health Network All Products |
$235.31
|
| Rate for Payer: Signature Care EPO |
$252.98
|
| Rate for Payer: Signature Care PPO |
$268.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$259.08
|
| Rate for Payer: United Healthcare Commercial |
$240.18
|
| Rate for Payer: United Healthcare Medicare |
$97.54
|
|
|
IOPAMIDOL 76 % IV SOLN 125 ML BTL
|
Facility
|
IP
|
$342.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103284
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$256.50 |
| Max. Negotiated Rate |
$318.06 |
| Rate for Payer: Aetna Commercial |
$295.49
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna All Commercial |
$295.15
|
| Rate for Payer: CORVEL All Commercial |
$318.06
|
| Rate for Payer: Coventry All Commercial |
$300.96
|
| Rate for Payer: Encore All Commercial |
$314.81
|
| Rate for Payer: Frontpath All Commercial |
$314.64
|
| Rate for Payer: Humana ChoiceCare |
$295.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.80
|
| Rate for Payer: PHCS All Commercial |
$256.50
|
| Rate for Payer: PHP All Commercial |
$259.37
|
| Rate for Payer: Sagamore Health Network All Products |
$264.02
|
| Rate for Payer: Signature Care EPO |
$283.86
|
| Rate for Payer: Signature Care PPO |
$300.96
|
| Rate for Payer: United Healthcare Commercial |
$269.50
|
|
|
IOPAMIDOL 76 % IV SOLN 125 ML BTL
|
Facility
|
OP
|
$342.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103284
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.02 |
| Max. Negotiated Rate |
$318.06 |
| Rate for Payer: Aetna Commercial |
$288.65
|
| Rate for Payer: Aetna Medicare |
$109.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$106.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$196.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$213.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$125.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$120.38
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Centivo All Commercial |
$186.05
|
| Rate for Payer: Cigna All Commercial |
$295.15
|
| Rate for Payer: CORVEL All Commercial |
$318.06
|
| Rate for Payer: Coventry All Commercial |
$300.96
|
| Rate for Payer: Encore All Commercial |
$314.81
|
| Rate for Payer: Frontpath All Commercial |
$314.64
|
| Rate for Payer: Humana ChoiceCare |
$295.39
|
| Rate for Payer: Humana Medicare |
$109.44
|
| Rate for Payer: Lucent All Commercial |
$186.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.80
|
| Rate for Payer: PHCS All Commercial |
$256.50
|
| Rate for Payer: PHP All Commercial |
$259.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$133.38
|
| Rate for Payer: Sagamore Health Network All Products |
$264.02
|
| Rate for Payer: Signature Care EPO |
$283.86
|
| Rate for Payer: Signature Care PPO |
$300.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$290.70
|
| Rate for Payer: United Healthcare Commercial |
$269.50
|
| Rate for Payer: United Healthcare Medicare |
$109.44
|
|
|
IOPAMIDOL 76 % IV SOLN 50 ML BTL
|
Facility
|
IP
|
$78.40
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
408103282
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$72.91 |
| Rate for Payer: Aetna Commercial |
$67.74
|
| Rate for Payer: Cash Price |
$47.04
|
| Rate for Payer: Cigna All Commercial |
$67.66
|
| Rate for Payer: CORVEL All Commercial |
$72.91
|
| Rate for Payer: Coventry All Commercial |
$68.99
|
| Rate for Payer: Encore All Commercial |
$72.17
|
| Rate for Payer: Frontpath All Commercial |
$72.13
|
| Rate for Payer: Humana ChoiceCare |
$67.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$70.56
|
| Rate for Payer: PHCS All Commercial |
$58.80
|
| Rate for Payer: PHP All Commercial |
$59.46
|
| Rate for Payer: Sagamore Health Network All Products |
$60.52
|
| Rate for Payer: Signature Care EPO |
$65.07
|
| Rate for Payer: Signature Care PPO |
$68.99
|
| Rate for Payer: United Healthcare Commercial |
$61.78
|
|
